A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

Rationale:

A. Urine output 20 mL/hr: This urine output is below the recommended minimum of 30 mL/hr and may indicate magnesium toxicity or worsening renal perfusion. It is not a therapeutic effect and requires prompt evaluation.

B. BP 150/92 mm Hg: This blood pressure is still elevated and does not indicate optimal control of preeclampsia. Magnesium sulfate is given to prevent seizures, not primarily to lower blood pressure, so this is not a measure of therapeutic effect.

C. Absence of eclampsia: Magnesium sulfate is administered in preeclampsia to prevent the onset of eclampsia (seizures). The absence of seizure activity indicates that the medication is having its intended therapeutic effect.

D. FHR 116/min: This fetal heart rate is within the normal baseline range of 110–160/min, but it is not a direct therapeutic effect of magnesium sulfate. It is more a reflection of fetal well-being rather than the drug’s primary purpose.